Provider Demographics
NPI:1639790041
Name:COHEN, MAXINE BETH (MFT)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:BETH
Last Name:COHEN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 LARKSPUR AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-2317
Mailing Address - Country:US
Mailing Address - Phone:949-644-6435
Mailing Address - Fax:
Practice Address - Street 1:517 LARKSPUR AVE
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-2317
Practice Address - Country:US
Practice Address - Phone:949-644-6435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC32638106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist